The Healthcare Program Integrity Analytic Consultant Senior - Data Analytics develops algorithms analyzing Medical, Dental. Managed Care, and Pharmacy claims data to detect fraud, waste and abuse. Prepares formal write-ups detailing the analysis performed while highlighting suspicious providers, trends, outliers and potential overpayments. Works with Data Analytics manager to refine analysis and prepare presentation to the State's Medicaid Program Integrity department, and collaborates with managed care organizations' special investigation units (SIUs). Essential Responsibilities
- Analyze health care claims data for the State Medicaid Surveillance Utilization Review Program Integrity department to identify potential fraud and abuse by providers and/or recipients.
- Prepare formal write-ups detailing algorithm parameters, programming and results; and, present effective, polished presentations of these results to clients.
- Research Iowa policies, provider manuals and provider communications; Federal and Iowa regulations and statutes; and coding guidelines related to analytic projects; translate this policy into data analysis.
- Perform drill down reporting on suspicious providers and/or recipients and create reports to show the dollars paid and the potential recovery.
- Provide recommendations for next steps in the investigation of algorithm results, opportunities for Iowa Medicaid policy clarification, provider education and/or claim edit enhancement as methods of cost avoidance.
- Work in a team setting and independently perform detailed claims analysis using Truven Health's tools which are proprietary software tools; participate in training to learn these tools.
- Update internal team databases and the case tracking tool to reflect project status.
- Peer review algorithm logic and write-ups for other Senior Analytic Consultants.
- Create draft provider audit letters and mail merges for completed algorithms.
- Provide on-site and/or telephone support (e.g., client inquiries, ad hoc reporting assistance, miscellaneous research, advice on analytic methods) and training as requested by client end users and management.
- Through the use of analytic findings, define problems and recommend appropriate solutions to clients, other team members and management taking into account the project budget, the sophistication of the user and the intended use of project results.
- Demonstrates increasing responsibility for completion and ownership of projects and/or tasks with a significant impact on a department or function.
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